Healthcare Provider Details

I. General information

NPI: 1588947097
Provider Name (Legal Business Name): ASHLEY MARIE DOLAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 MACCORKLE AVE SE
CHARLESTON WV
25304-2224
US

IV. Provider business mailing address

5430 MACCORKLE AVE SE
CHARLESTON WV
25304-2224
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-3627
  • Fax: 304-925-1163
Mailing address:
  • Phone: 304-925-3627
  • Fax: 304-925-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01531
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number630
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: